1. Day to Day Process and Quality Improvement: Hardwiring Plan/Do/Study/Act
Kathryn Harmes M.D.
PCMH Director, Department of Family Medicine
Grant M. Greenberg M.D., M.A., M.H.S.A.
Associate Medical Director for Quality, UM Medical Group
Associate Chair for Information Management and Quality, Department of Family Medicine

2. Disclosures
None to report for either speaker

3. Learning Objectives
Recognize standard methodology and tools for rapid cycle problem solving
Prepare and utilize Plan Do Study Act (PDSA) cycles for daily process improvement
Practice methods of conducting root cause analysis and relate its importance for successful Quality Improvement

4. What went wrong: problem solving is not simple
We come across issues every day in clinical practice
When things don’t go exactly right, do we always understand why?

5. Typical Problem Solving
Good people wanting to do the right thing and get work done, jumping to conclusions about perceived problems based on gut instinct and hearsay, applying poor fixes that are doomed to fail over the long-term.

6. Problems are Opportunities
“No problem is problem”
-Ohno, Toyota
“I haven't failed, I've found
10,000 ways that don't work.”
- Thomas Edison
Not all problems can be fixed, not all problems need to be fixed…and in fact, problems can be beneficial

7. Finding a Problem for Improvement
“If you don’t have standard work first, don’t expect any improvement” -Dave Lagozzo
Start by evaluating the current state
Required: consensus on desired outcome
“If we don’t know who owns the problem, it won’t get solved.” John Shook
“Success depends on leadership having conversation around the problems, not the outcome” Steven Spear

8. Finding the problem: Root Cause Analysis
5 Why’s
Flowcharts
Fishbone

9. Behind on Rx Refill Requests
5 Why Example
Behind on Rx Refill Requests

10. 5 Why Example High Volume of Requests this Week
Behind on Rx Refill Requests
High Volume of Requests this Week
Why

11. 5 Why Example Why Why Behind on Rx Refill Requests
High Volume of Requests this Week
No Clinic Appointments
Why

12. 5 Why Example Why Why Why Behind on Rx Refill Requests
High Volume of Requests This week
No Clinic Appointments
Everybody at STFM Mtg
Why
Why

13. 5 Why Example Why Why Why Why Behind on Rx Refill Requests
High Volume of Requests This week
No Clinic Appointments
Everybody at STFM Mtg
It’s a great meeting
Why
Why

14. 5 Why Example Why Why Why Why Why Behind on Rx Refill Requests
High Volume of Requests This week
No Clinic Appointments
Everybody at STFM Mtg
It’s a great meeting
I get to go to a workshop on PDCA
Why
Why
Why

15. Flowcharts Visual display of every step in a process
Can help identify: redundancy, complexity, delay, and waste in a process and answer the question “does each step add value?”
Value Stream Mapping - LEAN

16. Value Stream Map Example

17. Flowchart - UDS

18. Fishbone Diagram People, Process, Equipment, Materials, Environment
It helps teams understand that there are many causes that contribute to an effect
It graphically displays the relationship of the causes to the effect and to each other

19. Fishbone Diagram Problem People Process Equipment Material/Supplies
Environment

20. Diabetic Foot Exam Not Done! Monofilament broken Monofilament
People
Done, not updated in EHR to capture data
Process
Doctor forgets
Not Done!
Monofilament broken
Monofilament
not in exam room
Patient not in clinic for diabetes
Equipment
Material/Supplies
Environment (culture)

21. Know Normal From Abnormal. Right Now

22. Once you know the problem…then and only then can you work to solve it
Plan Do
Study/Check
Act/Adjust
We must get to actionable, measurable, processes in the future state that:
Eliminate root causes of waste / problems
Prevent similar problems from reoccurring
Make future re-occurrences visual

23. Plan
“A plan is an experiment you run to see what you don’t understand about the work” -Stephen Spear
“If you want to make God laugh, tell him your plans”. -Woody Allen
“When you’re not sure what to do next, that’s a good time to try something”.
-John Long, MD

24. PLAN (with a capital P) Have a well defined goal Form a team
Clearly define your intervention
List tasks needed to implement
Assign responsibility, due dates
Predict what will happen, determine how you will you define success

25. Data to Drive Change: Key Characteristics
Objective
Believable
Reproducible
Relevant
Accessible/Transparent

26. DO
Run the test
Suggest: small scale, pilot before larger scale if feasible
“Just Do It”
-Nike advertising campaign

27. Study/Check How do the results compare to the predictions? Reflection
If results differ from predictions, ask why?
Consider re-evaluating the original root cause analysis

28. Act/Adjust Based on the P/D/S portions of the cycle:
What modifications need to be made for the next cycle?
What did you learn?
IF the plan is working…set a time frame for re-evaluation (e.g. 30/60/90 days)
Streamline (eliminate wasted effort)

29. Final Thoughts Make success understandable and doable
Make it easy to see problems
Make it clear what to do when a problem is encountered
Make it clear what will happen after notifying supervisor of a problem

31. STEP 1
Generate a list of root causes that might contribute to low Chlamydia Screening rates
Use the technique of asking "why" 5 times, and/or use a fishbone diagram to evaluate for causes stemming from one of the main categories of problems: people, process, equipment, material/supplies, environment.
No Solutions!

32. STEP 2 What are your root causes?

33. STEP 3 Root Causes
1. Provider unaware of availability and reliability of urine testing 2. External labs not being captured into EMR 3. Providers not ordering at time of service 4. Providers uncomfortable ordering test due to sensitive nature of discussion 5. Patient not sexually active/declines testing NOW: Develop a PDSA plan using the worksheet

34. STEP 4/5
Look at your data.
Discuss with your small group:
Did your intervention have its intended impact? Why or why not?
What might you do as a next step?
What might you do differently next time?

35. Discussion Why does standard work matter?
Did you find the “right root cause”?
Did you have consensus?
What will you try when you return to your own clinic/setting?

36. Contact Info
Katy Harmes MD
Grant Greenberg MD, MA, MHSA
(for both of us!)

37. Please evaluate this session at: stfm.org/sessionevaluation